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Diabetic Carbohydrate Counting
& Diabetic Exchanges
Where can I find a dietitian who works with diabetic diets?
Visitors note: Updated 2008 diabetic exchanges
The following answers are based on "Choose Your Foods: Exchange Lists for Diabetes" published in 2008 by the American Diabetes Association and the Academy of Nutrition and Dietetics.
I am an adult nurse practitioner who sees many persons with diabetes. I am in need of a reference for exchange lists for my patients who eat predominantly Asian / Oriental foods and one for my orthodox Jewish patient who is out of the country 200 days per year. Can you help me?
This same request to The American Diabetes Association came up empty. Thanks for your assistance.
My husband is a diabetic and I work for a physician where I help other diabetics and their spouses learn how to change their method of eating. I also have recently started teaching a program that focuses on healthy eating and have learned to convert recipes to exchanges. Is there a software program that is available that you can enter the recipe and it will give you exchanges? Thank you for your help.
Don't know of any software that will convert recipes into exchanges as that is a very difficult process. I have written algorithms for a software program to convert whole foods into exchanges, but it made a lot of mistakes. So, I had to exchange foods by hand and it took a long time to exchange 5,000+ foods!
Any nutrition software package should have a dietitian involved in development or the software may have errors in formulas or nutrient data. A food database should be updated at least once every year and should contain basic foods and brand name foods as well as restaurant foods.
If you hear of any software that converts recipes into exchanges, please reply.
Why are "free vegetables" limited portions when cooked?
Non-starchy vegetables like 1/4 cup carrots, cauliflower, celery and green beans cooked or 1/2 cup raw cabbage or cucumber and any amount of greens are considered free foods because they contain less than 5 grams carbohydrate with less than 20 calories.
Some other examples of free foods are 1 tablespoon of fat-free versions of cream cheese, liquid creamer, margarine spread, mayonnaise or mayonnaise-style salad dressing, salad dressing, sour cream or regular whipped cream. Condiments such as 1 tablespoon of catsup, honey mustard, Parmesan cheese, pickle relish, soy sauce or taco sauce. As long as you eat less than 2 teaspoons, barbeque sauce, sweet and sour sauce and chili sauce are free whereas you can eat up to 1/4 cup of salsa.
Free foods do not count in carbohydrate calculations when they are eaten in moderation (less than 3 servings per day and not more than 1 per meal). The key word is moderation. These foods are not calorie free. For example, if one consumes 3 tablespoons of fat- free mayonnaise or salad dressing at one meal, it is counts as a fat exchange.
The exchange lists provide a quick way to estimate calories, carbohydrate, protein and fat content in any food or meal. Serving sizes in each exchange (starch, fruit, milk, vegetable, meat or meat substitute, and fat) are defined so that one serving of each food contains about the same amount of carbohydrate, protein, fat and calories.
I think you skipped over the part of my question that mentioned that for some meals in the month of meals five, some exchanges might have been substituted for others. It's right in the beginning of the book. How can I work with these meals given that a choice of exchanges are given, but not all lunch menus have the same exchanges.
For example, there's a dinner with humus. I like the humus, but I know there must be grains to provide a complete protein. So how can I calculate the carbohydrate and protein part of the whole meal when I can't know from variable exchanges listed for dinners the exact exchanges. I suspect that this portion of their 1500 calorie menu may contain more protein and I need to adjust the portions. How can I verify I need to do that and how can I do that?
Sometimes it's OK to move exchanges between meals in the same day as long as you don't exceed the total number of exchanges for the day. Remember to eat carbohydrate around the peak times for injected insulin.
The calories are similar for one starch or one meat exchange used in place of the milk exchange however starch and meat are not good sources of calcium. Also, one starch has the same calories and carbohydrate as a fruit exchange. The explanation in the front of the book was done so that the user could understand the flexibility of using the pre-planned vegetarian menus. Diabetic menus are planned for a whole day, not just a single meal. Individual meals can vary, especially if one is using carbohydrate counting which most people with diabetes use instead of the exchange list.
You can calculate the carbohydrate and protein content of a meal by referring to your exchange booklet and your question below. Protein content is 7 grams in one meat or meat substitute (1 ounce), 8 grams in one milk, 0 - 3 grams in one starch and 2 grams in one vegetable.
If you eat humus, you don't need to combine it with a grain at the same meal to get a complete protein. Eat a grain the same day as the humus. If the lunch meal plan has 1 meat substitute (7 grams protein), 3 starch servings (3 grams times 3 servings = 9 grams) and 2 vegetable servings (2 grams times 2 servings = 4 grams), the total lunch has 20 grams of protein. If you need to reduce the protein content at any meal, eliminate a starch and substitute a fruit which has no protein and you will reduce the protein content by 3 grams while keeping the same number of carbohydrates and calories.
You may want to refer back to your exchange booklet that lists foods in each exchange and the amount of food per serving. If you still need some help making some of these substitutions, see a registered dietitian to individualize your needs and introduce you to carbohydrate counting.
I have IDDM (Insulin Dependent Diabetes Mellitus) and am a 37 year old female, 5 feet 2 inch, 58 kilograms (128 pounds), 57 gram protein / day meal plan, up from 40 gram / day based on 0.8 gram / day healthy body weight. Protein was increased after a period with negative creatinine clearance tests. I've been trying to eat fewer animal sources of protein, hoping it would give me more quantity of food, but I'm stumped with the American Diabetes Association month of meals 5 (vegetarian) since it doesn't list carbohydrates per meal, only exchanges and it states in the book one exchange may have been substituted for another.
Each meal in the American Diabetes Associations Month of Meals lists the total exchanges per meal. Number 5 book is now called vegetarian.
If your protein has been restricted because of an elevated creatinine clearance (reflects breakdown of muscle and organs in the body which occurs in kidney disease), then you need high biologic value protein which are found in animal products. Animal sources of protein contain all 8 essential amino acids (complete protein). Egg protein is close to the ideal proportion of amino acids humans need.
If you are eating vegetable sources of protein, you may not be getting complete proteins from one day of meals. Unless you eat soybeans which are complete proteins.
I think it would be beneficial for you to see a registered dietitian to develop an eating plan that considers all your health needs.
I have to be on a 1200-calorie diet and I have lost the number of exchanges needed per meal. Please give me an average amount of veggies, fruits and starches per meal. I know the meats and milk but can't remember the other. I do not take insulin or medication. I am borderline.
The standard 1200 calorie meal plan is 4 meats (lean), 3.5 starch, 3 milk, 3 vegetables, 3 fruit and 5 fat. You can split the exchanges up into 3 meals or 3 meals plus 1 snack. Save 1 bread or 1 fruit for a snack.
There is no such diagnosis as borderline diabetes. Either you have diabetes or you don't and if you do have diabetes then you need to count carbohydrates. If you need additional assistance with your eating plan, contact a registered dietitian who could individualize your meal plan including your likes and dislikes.
What helpful hints do you have for converting homemade ice cream recipes for use by diabetics. Is it possible to substitute non-dairy creamers plus skim milk for cream? What substitutions can be made for the sugars?
What is the use of corn starch in recipes?
A recipe I found for homemade ice cream is as follows: 2 cups whipping cream, 2 cups light cream, 1 cup sugar, 1/1/2 teaspoon vanilla extract, 1/8 teaspoon salt. If you want to make French ice cream, add 1/2 box of instant pudding dry powder to above. Vary the flavors and fruit you put in the ice cream while freezing. This recipe (serves 8) has 270 calories, 17 grams fat, 27 grams carbohydrate and 1 gram protein. One-half cup of this homemade ice cream is 2 starch and 3 fat exchanges.
You could substitute plain yogurt for the whipping cream and evaporated fat-free milk for the light cream in above recipe. You could use 1/2 the amount of sugar in the regular recipe or use a new Splenda baking product that is half sugar, half sucralose. I wouldn't suggest replacing all the sugar with a low calorie sweetener as the product may not freeze. This modified recipe would have 140 calories, 1 gram fat, 24 grams carbohydrate and 8 grams protein. One half cup of this low fat frozen yogurt is 1 1/2 starch and 0 fat exchanges.
I would not recommend substituting non-dairy creamer for cream in ice cream because non-dairy creamers are usually made with palm oil which is a saturated fat. Cornstarch is a thickener for hot liquids like soup, gravy or sauces. Try using sugar-free instant pudding mix instead of cornstarch to make a French type ice cream. This will add 13 calories and 4 grams carbohydrate to each serving.
I am a diabetic. I love peanut butter. What is in peanut butter that you have to give up one fat exchange?
The usual ingredients in peanut butter are peanuts and salt. Some brands add hydrogenated vegetable shortening or sugar. Hydrogenated vegetable oil is a saturated fat which may be added to prevent the peanut oil from separating out while the jar is sitting on your grocer's shelf. Imagine your jar of peanut butter with a big spoonful of shortening added.
There are several brands of peanut butter available in the refrigerated section of most grocery stores that taste really good and don't have added hydrogenated vegetable oil. Peanut butter is made by grinding blanched (no skins), roasted peanuts and adding salt. The oil does not separate out as long as the peanut butter is refrigerated. The old fashioned or natural peanut butters on the grocery store shelf aren't refrigerated and the peanut oil separates out. So each time you want peanut butter, you have to stir the peanut oil back into the peanut butter or remember to turn the jar upside down before putting it away as the peanut oil will float to the top.
One tablespoon of peanut butter is exchanged for one high fat meat exchange. Peanuts contain some protein and fat in the form of peanut oil. So when you eat one serving of peanut butter (2 tablespoons) at a meal, exchange two meats and 1 fat at that meal. Peanut butter is a good breakfast meat substitute for an egg. Try peanut butter on whole wheat toast with one-half cup of orange juice or applesauce for a quick breakfast meal.
I'm a new diabetic and I would like to hear from you as to what you would suggest. Occasionally I like to have a brandy and seven. Since I can't drink regular pop, I've changed to diet pop. What about the brandy? How many can I have?
While I do not recommend that anyone drink alcohol, it should be limited by your doctor's recommendation. Usually that means no more than two alcoholic drinks per day for males with non-insulin dependent diabetes (Type II diabetes) who are in good blood glucose control. One alcohol serving is two mixed drinks with 1 1/2 ounces alcohol each or two 12 ounce beers or two five ounce glasses of wine. Also, each alcoholic drink contributes about 100 calories, so you will need to subtract 100 calories per alcoholic drink from your total food intake on days you choose to drink. The total amount of calories should remain the same for that day compared to other days in your eating plan.
I would like you to consider these suggestions. Pick two different days of the week (i.e. Friday and Monday) to have your two drinks. It will be easier to remember what day of the week today is, than when you last had your two drinks.
If you have an alcoholic drink make sure you eat. Plan to have a meal or snack at the same time. One effect of alcohol is that it shuts off your liver from releasing stored glucose from your liver into your blood stream which increases the likelihood of experiencing low blood sugar. Many of the symptoms of low blood sugar resemble intoxication (like dizziness, slurred speech, blurred vision, muscle weakness and a shaky feeling).
If you are on insulin or pills, the medication will continue to work and your blood sugar will drop when you drink alcohol and don't eat. Also, some diabetic pills may interact with the alcohol and cause facial flushing.
How do you exchange soup with the Exchange List? I cannot find it listed in my booklet. I make both canned and homemade soup for my husband who is a diabetic.
Most canned soups can be exchanged as follows: one cup reconstituted broth soups equals one starch; one cup reconstituted cream type soups equals one starch and one fat. Some soup companies do provide exchanges for each of their soups on labels.
If you are serving homemade broth soup as an accompaniment to a meal, serve 1/2 cup of solids and 1/2 cup of broth. (Hint: First measure the amount one soup ladle or serving spoon holds. Then you will know how many ladles equal ½ cup.) If your soup has potato, rice, noodles, dried beans or starchy vegetables such as corn or peas, exchange 1 cup serving (solids and broth) as one starch.
If instead you serve a hearty soup as a meal, make sure your soup has meat or poultry chunks, potato, rice, noodles or dried beans and vegetables. A serving could be 2 cups of solids and some added broth (one-half to one cup). Exchange this serving as two meats, two starch, one vegetable and 0 to 3 fats.
Remember to skim the fat off the soup before serving. If you make the soup a day ahead and refrigerate it overnight, the fat rises to the surface and hardens on top. Use a spoon or one of the new fat attracting mops to skim the fat off your hot soup. Bon Appetit!
I am a little confused about cheese and I am a diabetic. I know that 1/4 cup of low fat cottage cheese is permissible, but what about the hard cheeses like cheddar, American and so on? What is in them that we cannot have?
You can have hard cheeses and exchange cheese for meat in your eating plan. Hard cheeses like American, cheddar, Monterey Jack or Swiss are listed with the high fat meats. High fat meats are higher in fat (8 grams) and higher in calories (100 calories). When you eat one ounce of cheese, you should exchange one meat and 1/2 fat.
If you were to eat a slice of bread and cheese, you could omit spreading margarine or mayonnaise on one of the slices of bread. This would cut out the extra 1/2 fat exchange in each ounce of cheese.
Other cheeses like feta and mozzarella are medium fat meats. They have an average amount of fat and no extra fat exchanges have to be omitted when you eat these cheeses. One ounce of these cheeses are exchanged as one medium fat meat.
Cheeses, including 4.5% fat cottage cheese and Parmesan are lean meat exchanges and are similar to chicken or fish.
A person with diabetes can eat all varieties of cheese, preferably not cheese spreads, processed cheese or cheese food which are usually higher in fat and salt. A person with diabetes and high blood pressure should read the cheese food label for sodium content to determine if a particular cheese should be included in his / her eating plan. For persons with high blood pressure, 300 milligrams or less per serving is recommended.
I am a diabetic. Is it safe for me to eat honey graham crackers?
Yes, people with diabetes can eat honey graham crackers. The amount of honey or sugar in most brands of graham crackers (other than chocolate covered) is not considered significant.
Three graham crackers measuring 2 1/2 inches square is equal to one starch exchange. So if you would like, you can eat three grahams instead of one slice of bread. Remember, however, to reduce the starch exchanges in your diabetic eating plan when you eat graham crackers.
Why is the meat group in the Diabetic Exchange List separated into three groups? Do I have to have so many meals from each one each week?
The meat exchanges are divided into three categories: lean, medium fat and high fat. All meat groups have the same amount of protein, which is seven grams. The calorie content varies from 55 calories for lean meats and 75 calories for medium fat to 100 calories for high fat meats. The caloric difference between meats is their fat content. Lean meats have only 3 grams of fat, medium fat meats have 5 grams and high fat meats have 8 grams of fat. So, the higher fat content in the high fat meats is what increases the calories. Fat is the most calorie concentrated nutrient at nine calories per gram.
To limit your intake of saturated fats and cholesterol, choose mostly lean meats and medium fat meats (skinless poultry and turkey, round steak, fish, lean ground beef - at least 90% lean, cottage cheese, loin pork chops, low fat cheeses such as mozzarella). Limit high fat meats such as bacon (pork or turkey), ground pork, hot dogs (beef, pork, turkey or chicken), sausages, spareribs, sandwich meat, cold cuts and regular cheese to infrequent choices.
The American Diabetes Association's recommended guidelines for people with diabetes include a low saturated fat, low cholesterol eating plan. This is because people with diabetes develop more cholesterol deposits (atherosclerosis) in their arteries and at a younger age than people who don't have diabetes. The cause of this increased rate of atherosclerosis is unknown, but higher sugar or insulin levels in the blood may be the reason.
I have been trying to follow the Exchange List diet, but am tired of dragging along a food scale to weigh my meat. When I eat out, I try to stick to chicken, pork chops or steak, but this is the time of year for banquets with roast beef and turkey. Do you have any suggestions?
Yes, try this trick I learned several years ago from another registered dietitian.
Take a look at the back of your hand. Look at the two bones that stick out on the side of your wrists. From that point where your wrist bends, up to your knuckles where your fingers start and as thick as your little finger is wide is the size of approximately three ounces of meat, fish or poultry. The piece of meat should be only as thick as your little finger is wide, looking at your finger from the side. Granted, the sizes of people's hands do vary, but so does their calorie and protein needs. So persons with large hands, especially men, may have hands that would compare to four ounces of meat, but their eating plan would probably be higher in calories and protein also. You always have your hand with you. So just look at the back of your hand as you reach for a piece of meat. Take a serving as large as the back of your hand and as wide as your little finger. If the meat is served to you, cut off a hand size piece before you start. Push the excess off to the side of your plate and enjoy the hand size piece you cut.
Another suggestion is choose a 3 ounce serving of meat that is about the size of a deck of cards.
My husband was just diagnosed as having diabetes. He's not taking any shots or pills. His doctor suggested we see a registered dietitian to get a diet. The hospital dietitian gave him a book called "Exchange List" and explained it. The list is pretty complicated and so different from the way we eat. Couldn't he just cut out sugar and sweets instead of having to follow exchanges?
No. Just cutting out sugar and sweets isn't enough for a person with diabetes to control his or her blood sugar. This total food intake for the day and especially the amount of carbohydrate should be determined to reach a healthy weight and include 30 minutes of activity each day. It should also take into account his food preferences and eating habits.
For instance, if his prescribed diabetic meal plan was for 1800 calories and he only ate two meals of 900 calories each, his blood sugar would probably go higher than desired. Instead, if he ate 3 meals and 1 or 2 snacks, the calorie content at each meal would be much lower at around 500 calories. Also, his blood sugar would be more likely to stay within desired ranges of less than 140 milligram per deciliter two hours after meals.
The diabetic exchange list groups foods together that have similar protein, fat and carbohydrate content. The exchange list is the basis for carbohydrate counting now used in diabetic eating plans. Now you can exchange starches, milk and fruit for each other at a meal because they have the same carbohydrate content per serving.
For instance, the fruit exchange includes all fruits that have 60 calories and 15 grams of carbohydrate per serving. Unfortunately, nature did not put the same amount of carbohydrates in each kind of fruit, so the serving size varies between fruits.
The milk exchange includes fluid milk (fat-free skim, buttermilk or soymilk), plain yogurt and plain kefir. One milk exchange has 15 grams of carbohydrate, 8 grams protein and 0 (skim or fat-free) to 3 grams fat (1% or low fat versions) with 90 to 100 calories. Reduced fat 2% milk has an additional 1 fat exchange and whole milk an additional 1 1/2 fat exchanges compared to skim milk. Imagine 1 teaspoon or 1 1/2 teaspoons of butter floating in reduced fat or whole milk. So if you drink reduced fat or whole milk, you will need to deduct some fat exchanges from your meal plan to account for the fat if you drink reduced fat or whole milk.
The starch exchange includes bread, cereal, rolls, crackers and starchy vegetables like corn, peas, winter squash and potatoes. One starch exchange has 15 grams of carbohydrate, 3 grams of protein and a trace of fat with 80 calories.
Doctors and dietitians have used the exchanges (milk, vegetable, fruit, starch, meat and fat) nationwide to simplify diabetic eating plans. The exchange list has evolved into carbohydrate counting where a serving of a food with 15 grams of carbohydrate is called a carbohydrate choice. It is easy to keep track of your carbohydrate choices when you have 2 to 4 per meal and 1 to 2 per snack. Counting calories while eating is very time consuming and tedious. An exchange list eating plan will present you with variety and more likely, an adequate amount of vitamins and minerals.
It sounds like you have some more unanswered questions. I would suggest, you both see a dietitian again to answer them. Your husband needs to know what and how much he can eat. You both need to know what and how much to cook. Once you get used to using exchanges, I believe, you will rely on them for every meal.
I love your web site and think you're doing a great service for the dietetics profession. I am also a registered dietitian with a Masters in Health Science. I work at a 600-bed hospital in a major southeastern city. My clinical emphasis for the last four years has been in nutrition support.
Here's my question: a dieter recently asked me what my impressions were of the Richard Simmon's Deal-A-Meal program. Not having much experience with this product, I was wondering what you thought?
FYI, Richard Simmons didn't develop the deal a meal, a dietitian did as an educational tool. She sued Richard Simmons and I remember that she was awarded damages.
Deal a meal is based on the exchange system, but uses individual cards for each exchange. The person moves cards from one side of a folder to the other to keep track as exchanges are eaten each day. I haven't keep close track if Richard Simmons has made any changes to what the dietitian developed. I don't believe the deal a meal diets are individualized like a dietitian would do with an exchange diet for weight loss. I also don't know if there are various calorie levels for deal a meal so maybe one "size" deal fits all. Whereas, a dietitian could customize the calorie intake and meal plan to the individual.
Thanks for the positive feedback. It is nice to hear, especially from peers. I used to do nutrition support and loved it.
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